Basic Information
| Provider Information | |||||||||
| NPI: | 1679665244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER CITY NURSE MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 DATAPOINT DR | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106140180 | ||||||||
| FaxNumber: | 2106157170 | ||||||||
| Practice Location | |||||||||
| Address1: | 8811 VILLAGE DR | ||||||||
| Address2: | ATTN FAST TRACK | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782175415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106140180 | ||||||||
| FaxNumber: | 2106157170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | FACEP | ||||||||
| AuthorizedOfficialTelephone: | 2106140180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0033PC | 01 | TX | BCBSTX | OTHER | 186228602 | 05 | TX | MEDICAID |